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FROM : J.Schetter PHONE NO. : 5306667692 • Mar. 21 2005 04:57PM PS UNI.FIEA PROGRAM CONSOLIDAY'ED FORM 'WANK UNDERGROUND STORAGE TANKS-TANK PAGE 2 l,,tte_ of_. VI.P(PLNG CONSTRUCTION(ch+ckallcna,a y) AH vEGROUND PIPING UNDERGROUND PIPINGIj S.GRAVITY 459 SYSTEMTYPE 1.PRESSURE ❑2.SUCTION r]3.GRAVITY 458 ❑1.PRESSURE [7 2. SUCTION 95.UNKNOWN 462 CONSTRUCTION ❑1.SINGLE WALL C],;,LINED TRENCH El99.OTHER 460 ❑1.SINGT,E WALL ❑ �2.DOClBLh.WALL. ❑99.OTHT+R 463 Up�nKpR ®2.DOUBLE WALL [195.UNKNO`1N 461 MANUFACTURER MANUFAC"MEP ❑6.FRP COMPATIBLE W/1oo?k(viPTHANOL ❑t.BART STEEL ❑6.FRP COMPATIBLE w/IW% METHANOL ❑I.BARS.STEEL. a 1.GAL.VANI7.>D ST'EL ❑2.STAINLESS STEEL ❑7.GALVANIZED STEEL I ❑U¢known ❑2. 1 1'AINLI:SS STEEL 13 3.PLASTIC COMPATIBLE W/CONVNTS ❑99. Other ❑3. PLASTIC COMPATIBLE W/CONTrNTS 9 CATS 1 DIC MOTEL"fniON O11�R 1'4. FIBERGLASS 465 ®4.FISERGLASS 0 S.FLEXIBLE(14DPE) ❑95.UNKNOWN 0 5.STEEL WICOATING ❑9.CATHODIC PROTECTION 464 ❑5, STEEL w/COATING VIL PIPING LEAK DI )ON(Chuck all that cep I )(A tkacri tion urthe mordtoan r0yJo n shall VT(YIZOUND I'IPINC)ubmittootothelool y) UNDF.RGROUNO PLI'ING467 4�, SINCrLE WALL PIPING SINGLE:WAIL PII'L'VG PRk.SSURIZ'FD PIPING(Chuck all that apply) PRESSURMED PIPING(Check all that apply): AUTO PUMP ❑1.ELECTRONIC LINE LEAK DETECTOR 3.0 GPI4 TEST V!TM AUTO PUMP SHUT ❑1, SHUTIOONIC LINE LEAK DETI FOR 1,PAK,SYSTEMFAIL 3.0 GPH TEST. T CISCO OFT-FOR LEAK,SYSTEM FAILURE,AND SYSTEM I-)ISCONNb'CTION AUDIBLE FAND VISUAL AI,RMS FAILURE,AND SYSTEM p1SCONNECTIUN+ AUDIBLE AND VISUAL ALARMS. C]2 MONT1LLY 0.2 GPH TAST C]2.MONTHLY 0.2 GPH TEST ❑3.ANNUAL INTEGRI"T"Y TEST(0.1GPH) C)3.ANNUAL INTEGRITY TEST(O.IGPH) ❑4. DAILY VISUAL.CHECK CONVENTIONAL SUC'IION SYSTEMS CONVP,Nl70NAL SUCTION SYSTEMS(Check all that apply) ❑ S.DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIAL PIPING ❑5. DAILY VISUAL MONITORING OF PIPING AND PUMPING SYSTEM INTEGRITY TEST(0.1 GPH) SAFE SUCl7014 SYSTEMS(NO VALUES IN BELOW GROUND11TING); ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPI 1) ❑7.SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLAW ❑7. SELF MONITORING ❑9.BIENNIAL INTEGRITY TEST(0.1 GPI) GRAVITY FLOW(Cheek At that apply). [IS. DAILY VISUAL.,MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 CPR) SECONDARILY CONTAINED PIPING SleCONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check ull that apply)' PRESSURIZUD PIPING(Check all that apply) 10. CONTINUOUS TURBINT SUMP SENSOR AUDIAI.1?AND VISUAL 10, (:aN INUOUS TURBINE SUMP SENSOR MM AUDISU;a:N()VISIlAL ALARMS AND(Chock Otte) ALARMS AND((.'hock one) ❑a, AUTO PTIMP SHUT OFF WHEN A LEAK O(;CURS ❑a AUTO PUMP SHUT'OFF WHEN A LEAK OCCURS ®b. AUTO PUMP 314UT OFF FOR LEAKS,SYSTEM FAILURP.AND SYSTEM ❑b AljT0 PUMP SHUT OFF FOR LEAKS,SYSTCM FAILURE AND SYSTEM DISCONNT3CTI0N DISCONNECTION Cc. NO AUTO PUMP smJT OFF ❑c NO AUTO PUMP SHUT OFF ®11. AUTOMATIC LINE LEAK T)F.TF.CTOR(3.0 GPH TEST)WITH FLOW SHUT ❑11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION j ❑12. ANNUAL INTEGRITY TEST(0.1(;PH) ❑12 ANNUAL INTEGRITY TEST(0.1 GPH) 1 SUCTTONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑ 13. CONTINUOTS SI IMP SENSOR I AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) 1:114, CONTINUOUS SUMP SENSOR WITHOUT ALCTO PUMP SHUT OFF` ❑14. CONTINUOUS SUt,4P SENSOR TS-Q!;,T AUTO PUMP SHUT OFF a Al)DIBU AND VISUAL ALARMS ALJDII31_E AND VISUAL ALARMS ❑15. AUTOMATIC LINE LEAK DETECTOR(3A GPH TF.ST)WITMOIJT FLOW El 15. AUTOMATIC LINE LEAK DEI.I,:CIOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16.ANNUAL INTEGRITY TEST(0.I GPH) ❑16.ANNUAL TNTEORITY TEST(0.1 GPH) ❑17. I,)A1i.,Y VISUALCHHCK I ❑ 17 DAILY VISUAL CHECK VIII.DISPENSER CONTAINMENT DLSPFNSER CONTAINMENT ❑1.FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 0 4.DAILY VISUAL CHECK DATE.TN'TALL.PD 4ea I]2 C0NTTMJ0I T.S DTSPRNSF.R PAN SRNSOR*ATMMI.R AND VISUAL,ALARMS ❑5.TRENCH LINGR/MONITORING ®3.CONTINUOUS DISPENSER PAN SENSOR WITH AUIU SHUT OF'6 FOR �6.NONE 409 DISPENSER+AUDIRLF.AND VISUAL Ai,ARMS IX.OWNER/OPERATOR SIGNATURE I acetify that thein ion ptrvided herein i8 true and necurate to the best of my knowledge. Sl(jNATURH OF )WN /OPFR -, LATE 470 03/21/2005 NAME OF OWOPRATOR(pt a TITLE OP OWNPP/OPERATOR 472 John Scllt LC Environmental Compliance S ecifist Permit Number(Oo I use only) 473 Permit App*owxt(Fpr loexl..only) P-4 RNPirayion Cato(por local uao only) 7